Pancreatic enzymes

Good nutritional care improves outcomes and is critical for your quality of life. The Pancreatic Cancer Action Network strongly recommends that patients have access to pancreatic enzymes and see a registered dietitian.

What are pancreatic enzymes?

Pancreatic enzymes help break down fats, proteins and carbohydrates. A normally functioning pancreas secretes about 8 cups of pancreatic juice into the duodenum, daily. This fluid contains pancreatic enzymes to help with digestion and bicarbonate to neutralize stomach acid as it enters the small intestine.

Types of Pancreatic Enzymes and Their Effects

Lipase

Effects:
Lipase works with bile from the liver to break down fat molecules so they can be absorbed and used by the body.

Shortage may cause:

Lack of needed fats and fat-soluble vitamins.

Diarrhea and/or fatty stools.

Protease

Effects:
Proteases break down proteins. They help keep the intestine free of parasites such as bacteria, yeast and protozoa.

Shortage may cause:

Allergies or the formation of toxic substances due to incomplete digestion of proteins.

Increased risk for intestinal infections.

Amylase

Effects:
Amylase breaks down carbohydrates (starch) into sugars which are more easily absorbed by the body. This enzyme is also found in saliva.

Shortage may cause:

Diarrhea due to the effects of undigested starch in the colon.

Reasons to Take Pancreatic Enzymes

Pancreatic insufficiency is the inability of the pancreas to secrete the enzymes needed for digestion. Having an insufficient amount of pancreatic enzymes is very common among people with pancreatic cancer. When the pancreas does not produce enough enzymes to break down food, pancreatic enzyme products are needed. Doctors sometimes prescribe digestive enzymes, including pancreatic enzymes, to patients who have conditions that cause poor absorption. These products help improve digestion and absorption of food.

Some of the conditions that may cause pancreatic insufficiency include surgery (Whipple procedure or total pancreatectomy), blockage or narrowing of the pancreatic or biliary duct (the tubes that carry pancreatic juice or bile), pancreatic or duodenal tumors, cystic fibrosis or pancreatitis.

Some of the symptoms associated with pancreatic enzyme insufficiency include:

feelings of indigestion

cramping after meals

large amounts of gas

foul smelling gas or stools

floating or greasy/fatty stools

light-colored, yellow or orange stools

frequent stools

loose stools

weight loss

Patients with these symptoms should discuss with their medical team whether taking supplemental pancreatic enzymes may be beneficial for them.

About 25% of patients who have the Whipple procedure will have long-term malabsorption and will need to take supplemental enzymes for life. Other patients may need enzymes for a few months or years after surgery. Patients who have radiation therapy along with the Whipple procedure are much more likely to have long-term malabsorption. Fat absorption usually does not return to normal in these patients even if they are taking enzyme replacement products. In this case, the goal is to eliminate diarrhea, restore adequate nutrition and prevent weight loss.

MCT (Medium Chain Triglyceride) oil may help control weight loss in patients with uncontrolled malabsorption. MCT oil is a calorie-rich type of fat that bypasses usual fat absorption and is rapidly absorbed by the body. It is found naturally in coconut oil, palm kernel oil and butter. MCT oil is added to some medical nutritional supplements and can also be purchased alone as a nutritional supplement. Use of oral nutritional supplements may promote weight gain, help increase strength and physical activity, and improve quality of life.

In patients with unresectable (non-operable) cancer in the head of the pancreas, bile duct and/or pancreatic duct obstructions are common. For these patients, a combination of pancreatic enzyme replacement therapy, nutritional counseling and drainage of the bile duct can prevent weight loss and improve symptoms.

Sources of Supplemental Pancreatic Enzymes

Pancreatic enzyme products are available in both prescription and non-prescription forms. The different brands of pancreatic enzyme products are not identical. All prescription pancreatic enzyme products are regulated by the United States Food and Drug Administration (FDA) to ensure their effectiveness, safety and manufacturing consistency.

Over-the-counter pancreatic enzyme supplements are available without a prescription. Since they are classified as dietary supplements rather than drugs, the FDA does not control their production. While manufacturers of over-the-counter supplements are required to ensure the safety of their products, there are no controls on manufacturing consistency from one batch to the next. Therefore, these products are not recommended for use in patients with pancreatic cancer.

The recommended type and dosage of pancreatic enzymes must be individualized for each person. Most people should start off by taking 10,000 – 20,000 lipase units with snacks and 20,000 – 40,000 lipase units with meals. Patients should not exceed 2,500 lipase units per kilogram of body weight per meal (assuming 4 meals per day). For example, a person that weighs 150 pounds (68kg) could safely take up to 170,000 units of lipase at one meal. Some individuals adapt to different doses of enzymes throughout their care. It is important to discuss with a doctor or dietitian the appropriate type and dose of pancreatic enzymes at regular visits.

Prescription Pancreatic Enzymes

All prescription enzymes come from a porcine (pig) source. If a person has allergies to porcine products, consult a doctor and/or dietitian for alternative options.

Taking Pancreatic Enzymes

The doctor may prescribe an acid-reducing medication to help improve the effectiveness of some pancreatic enzyme products. Acid reducing medications include proton pump inhibitors, such as esomeprazole (Nexium®) or omeprazole (Prilosec®), and H2 blockers, such as famotidine (Pepcid®), cimetidine (Tagamet®) and ranitidine (Zantac®). Not all pancreatic enzyme products require an acid-reducing medication for optimal activity. Talk to a doctor, dietitian or pharmacist for advice about whether or not an acid-reducing medication may be beneficial.

Tips to obtain the best results from pancreatic enzymes:

Take enzymes with every meal or snack that contains fat, especially meat, dairy, bread and desserts.

Start with the smallest dose necessary. Adjust according to the severity of the pancreatic insufficiency. As further alterations may be needed from time to time, it is important to keep an open dialogue with your doctor or dietitian.

Take the enzymes at the beginning of the meal or snack. This is very important for proper enzyme functioning. When taking multiple enzymes, take some at the beginning of the meal and the rest at various points throughout the meal. Enzymes generally do not work well if forgotten and only taken at the end of the meal.

Swallow intact tablets and capsules with liquid at mealtimes. Some enzyme products have a special coating to prevent breakdown in the stomach. The tablets should not be crushed or chewed unless directed by a member of your medical team.

If repeatedly held in the mouth for a length of time, certain pancreatic enzyme products may begin to digest the mucous membranes and cause irritation. This can lead to sores in the mouth, lips and tongue. If swallowing a capsule is difficult, open the capsule and add its contents to a spoonful of soft food that does not require chewing and can be swallowed immediately. Some recommended foods are applesauce, gelatin, pureed apricot, banana or sweet potatoes.

To promote enzyme function, do not mix the contents of the capsules (microspheres) with milk, custard, ice cream or other dairy products before swallowing. These foods have a higher pH that may dissolve the microspheres’ coating and destroy enzyme activity before they reach the stomach.

Pancreatic enzymes may have reduced effectiveness if taken at the same time as calcium- or magnesium-containing antacids, such as Maalox®, Mylanta®, Tums®, Rolaids® and others.

Use enzymes prior to their expiration date; otherwise, they may lose their effectiveness.

Side Effects of Pancreatic Enzymes

The most common side effect of pancreatic enzymes is constipation. Enzymes may also cause nausea, abdominal cramps or diarrhea, though these symptoms are less common.

Discontinue the use of pancreatic enzymes if any signs of hypersensitivity or allergic reaction appear. As pig/porcine is used in the preparation of prescription enzymes, people with allergies or religious guidelines related to pig products should work with their pharmacist, dietitian or doctor to find an appropriate enzyme preparation. Pancreatic enzymes may decrease the absorption of some iron salts. Tell the doctor and registered dietitian about all current medications and medical conditions while discussing the use of pancreatic enzymes.

If taken properly, pancreatic enzymes can help prevent weight loss and control symptoms associated with pancreatic enzyme insufficiency. Ask the doctor to prescribe the proper pancreatic enzymes for you.

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Information provided by the Pancreatic Cancer Action Network, Inc. (“PanCAN”) is not a substitute for medical advice, diagnosis, treatment or other health care services. PanCAN may provide information to you about physicians, products, services, clinical trials or treatments related to pancreatic cancer, but PanCAN does not recommend nor endorse any particular health care resource. In addition, please note that any personal information you provide to PanCAN’s associates during telephone and/or email communications may be stored and used to help PanCAN achieve its mission of assisting patients with, and finding cures and treatments for, pancreatic cancer. Stored constituent information may be used to inform PanCAN programs and activities. Information also may be provided in aggregate or limited formats to third parties to guide future pancreatic cancer research and treatment efforts. PanCAN will not provide personal directly identifying information (such as your name or contact information) to such third parties without your prior written consent unless required or permitted by law to do so.

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